Healing Our Heroes Retreat Initial Intake Form: Name * First Name Last Name Email * City and State Enter your city and state of residence Phone * (###) ### #### Which retreat are you interested in attending? * Location to be Announced June 2025 Florida December 2025 Colorado September 2025 Are you a...? * Veteran First Responder Retired Personnel from Intelligence Community Can you provide proof of service (DD214, etc...)? * Please add a copy of your DD214 or other proof of service to your application form. Yes No Financial Requirement for the Retreats, (At this time we are unable to provide full scholarships due to financial constraints.) * The total cost of each retreat is $2000 per participant, plus an additional $75 mental health evaluation fee for our therapist. We ask each participant to pay a portion of the cost and we try to fundraise for the rest. Each participant donates what they can afford with the minimum required donation being approximately $675 towards the cost of the retreat. If you have extenuating circumstances and need a bigger scholarship please reach out to us on some occasions we are able to provide a greater amount for those that are in need. (The minimum cost slightly varies depending on the state and venue where we are holding the retreat.) That donation money goes to help a fellow participant come on the retreat and then another participant donates towards your cost-share. This way each of our veterans or first responders is assisting another veteran or first responder to get the healing they need. Helping us in our mission of never leaving anyone behind! I am able to pay the full amount ($2000) I am able to pay half the amount ($1000) I am only able to pay the minimum participant cost share, plus the $75 mental health evaluation fee. Briefly describe your motivation(s) for attending one of our retreats and what you hope to gain from the experience * Do you have a mental health diagnosis? * Yes No Unsure Are you currently under the care of a licensed mental health professional? * Yes (please explain below) No If you answered yes to the above question, please explain further. Do you have prior experience with Ketamine Therapy? Yes No Do you have a disability that affects your activities of daily living? There will be a medical screening by the medical team that runs the medical program on the retreat for each person prior to attending. HOH only helps to provide the lodging and food. The medical team will reach out to you separately for more information. Yes No If you answered yes to the above question, please explain further. Are you willing to follow up with a licensed mental health professional of your choosing following the retreat? * Yes No (please explain further below) If you answered no to the above question, please explain further. Any history of substance abuse? * Yes (if willing, please explain further) No If willing and you answered yes to the above question, please explain further. * Are you willing to share your current medications and health diagnosis before attending? Yes No Maybe If you were in crisis, who would you reach out to? * Who is your emergency contact (name/phone number)? * Is there anything else you would like us to know? Do you have any dietary requirements? * Our retreats our vegetarian, sugar free, and gluten free. They do include eggs and organic vegetarian dairy. Our goal is to help heal both the mind and the body. Please let us know if you have any special dietary considerations such as celiac disease, food allergies, history of bariatric surgery or any other dietary issues we should know about. I do not have any special dietary considerations I have some special dietary needs that I will need to discuss with the team. Thank you!
